inquest into the death of anthony william young, shaun ... · aid for management of bleeding, and...

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Inquest into the death of Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan,

Laval Donovan Zimmer and Troy Martin Foster

Between August 2013 and November 2014, officers from Queensland Police, acting in the course of

their duties, shot and killed five men in unrelated incidents. The incidents occurred at the Sunshine

Coast, Brisbane and the Gold Coast. In particular, three of the deaths occurred over the period of

one week from 18 November 2014 and 24 November 2014.

State Coroner Terry Ryan conducted separate inquests into each of the deaths and on 20 October

2017 delivered his comments and recommendations.

The Queensland Government responds to recommendations directed to government agencies at

inquests by informing the community if a recommendation will be implemented or the reason why a

recommendation is not supported.

The departments named in this response will provide implementation updates until the

recommendation is delivered. Further information relating to the implementation of

recommendations can be obtained from the responsible minister named in the response.

Recommendation 1 The Queensland Police Service implement a model of incident command training for all operational police below the rank of sergeant.

Response and action: the recommendation is implemented.

Responsible agency: Queensland Police Service.

On 16 July 2018 the Minister for Police and Minster for Corrective Services responded:

Incident command training is currently delivered to all constables as part of the constable

development program workshop which includes virtual reality scenarios.

In addition, scenario-based training incorporating incident command, incident appreciation and

briefings were delivered to officers in 2016 and 2017, as part of the compulsory operational skills

and tactics (OST) training.

Additional briefings and handover elements of incident command will be incorporated into the

2018-19 OST dynamic interactive scenarios, in addition to compulsory online learning which will

complement the face-to-face training.

Elements of this training material were incorporated into the 2016-17 and 2017-18 OST online

learning scenarios. The 2018-19 OST online learning has not yet been developed, however, incident

command training will be incorporated into the dynamic interactive scenarios training.

On 8 January 2019 the Minister for Police and Minster for Corrective Services responded:

The Incident Command Training Section is implementing ‘Train the trainer’ incident command

supervisor workshops that will be rolled out statewide. The purpose of this training is to improve the

delivery of incident command workshops which can be facilitated within each district on a more

regular basis. This will ensure a greater number of frontline police are trained in incident command

techniques.

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Additionally, the QPS invested in a computer-based training platform which delivers scenario-based

training. The system is user friendly and can be tailored to meet the needs of target audiences. The

Incident Command Training Section will utilise this system to incorporate practical based training

that bolsters theoretical learnings.

The training system was implemented and trialled for six weeks from 17 September to 12 October

2018. The new training system complements current virtual reality technology. The first contingent

of officers was trained in September 2018.

Recommendation 2 The Queensland Police Service review operational skills and tactics training to incorporate training on appropriate radio communication and active listening techniques to ensure the effective transfer of information, and to assist frontline officers to recognise critical information.




The operational skills and tactics training (OST) includes a strong focus on de-escalation techniques

including the policing with influence communication model, behavioural stairway influence model,

and active listening techniques designed by the Negotiator Coordination Unit. In addition, the use of

radio communication under stress has been included as part of the 2017-18 and 2018-19 OST

dynamic interactive scenario training (DIST), and will continue to be part of DIST in the future.

The Queensland Police Service reviews the OST curriculum annually, and incorporates review recommendations and external consultation feedback, as required.

Recommendation 3 The Queensland Police Service revise its policy regarding first aid training for operational police so that it is consistent with the current guideline issued by the Australian Resuscitation Council.




All Queensland Police Service work units ensure compliance with the required ratios for the number

of members trained in first aid.

In addition, Tactical First Aid Training (TFAT) has been incorporated into the compulsory annual

operational skills and tactics training (OST) for all police. TFAT does not replace first aid certification,

however, comprises more relevant practical components for operational police. Both the first aid

training and TFAT align with the Australian Resuscitation Guidelines, in particular section 9.1.1 First

aid for management of bleeding, and is reviewed annually as part of the OST curriculum review.

TFAT incorporates in-depth training in the management of external bleeding by direct pressure,

treatment of embedded objects and the application of tourniquets, modular bandages, wound

packaging and chest seals.

As at 24 July 2018, 9794 members of the service have completed TFAT as part of compulsory annual operational skills training in the 2017/2018 training year. The techniques taught in TFAT have been applied successfully in operational situations and are credited with potential lifesaving outcomes in more than nine cases.

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Recommendation 4 The Queensland Police Service (QPS) continue to review its method for reporting the use of force applied by operational police with a view to implementing a system that would provide the QPS with accurate data that can be used to better inform use of force policy, reporting and training.




The Queensland Police Service (QPS) currently collects use of force data through QPRIME for

incidents involving injury and a small number of other specialised deployment situations (eg.

presentation of a firearm). This is a minimalistic approach and is not consistent with best practice

use of force data collection methods. The QPS acknowledges the need for a wider data collection

process to gain a broader appreciation of use of force deployments within the QPS.

The data collected through this process is intended to identify what areas are exhibiting excessive

force, which will inform future policy and training requirements to minimise the levels and

prevalence of force used by QPS officers. To facilitate the data collection process and to gather

additional data, the QPS will be lowering the reporting threshold.

The QPS Ethical Standards Command (ESC) established a project team to engage with frontline and

digital systems to define the technical requirements that will complement a police intranet reporting

use of force reporting solution. The project team undertook extensive consultation with officers in

charge across the state to assist in forecasting the potential impacts on frontline policing operations

and potential solutions.

It is expected the changes to QPRIME will be implemented in early 2019. These changes will require all officers to make additional entries into QPRIME for non-injury use of force incidents. The QPRIME information will be used by the QPS to provide more accurate external reporting of use of force data, in line with other police jurisdictions. This data will be used to complement existing early intervention strategies employed by ESC.


The development of the proposed additional QPRIME based use of force reporting requirements is currently being undertaken. This involves both the development of additional QPRIME data entry fields and reports to extract the data in a useable format. Once developed these new data entry fields and data extraction reports will require testing and validation prior to a ‘live’ QPRIME system release.

Additionally, current QPS use of force reporting policy will require amendment and all QPS officers will be required to be advised of and trained in the new use of force reporting system (over 11,500 officers).

The QPS has projected that full implementation should be finalised by mid-2019.

On 2 May 2019 the Minister for Police and Minister for Corrective services responded:

The QPS is continuing to develop the additional QPRIME-based use of force reporting requirements and full implementation should be finalised by July 2019.

The QPRIME custody report ‘use of force’ (UoF) tab went live in April 2019 and is being utilised by police in the field. The mandatory use of the field to record UoF incidents commences in June 2019.

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New QPS policy/guidelines and implementation training were developed and will be included in the operational skills and tactics training 2019/2020 curriculum to be completed by all QPS officers.

Consultation with the QPS union has been conducted.

These changes will enable the QPS to accurately report UoF across the organisation at a lower threshold as recommended by various stakeholders and in line with national benchmarks, while also providing for the first time the functionality of statistical analysis of UoF occurrences that could shape future training needs.

On 26 November 2019 the Minister for Police and Minister for Corrective Services responded:

The use of force custody tab became mandatory on 1 June 2019. The Queensland Police Service

amended the Operational procedures manual and the QPRIME user guide, and incorporated the tab

into the operational skills and tactics training curriculum.

Implementation of the use of force custody tab allows the Queensland Police Service to accurately collect use of force data and report on a lower threshold (which aligns with several external recommendations and benchmarks). The data collected allows for greater transparency in use of force reporting and enable statistical analysis which will assist in shaping future training needs and provide guidance in improving proactive approaches.

Recommendation 5 The Queensland Police Service (QPS) conduct a review with respect to how often, and in what manner, firearms skills should be refreshed in order to maintain effective performance under stress, and that as part of that review the QPS consider whether operational skills and tactics firearms training should occur more often than once every calendar year.




All Queensland Police Service officers are required to attend firearms training once every calendar

year using live fire ammunition, in addition to dynamic interactive scenario training (DIST) which

uses less than lethal rounds. DIST forms part of the mandatory operational skills and tactics training

and enables trainers and other senior officers to monitor and assess an officer’s performance and

decision making skills under stress, and to determine if further training or development is required.

The QPS approached the University of Queensland to assist in an evidence-based study regarding

the frequency of live fire training and the shot placement of firearms in operational incidents.

Supplementary training sessions, based on relative demand, are also under development to support local needs.


The QPS has submitted a request to the Australian and New Zealand Policing Advisory Agency (ANZPAA) for data relating to national police training and police shootings. The data collection and analysis processes are underway.

The QPS is waiting for responses from some jurisdictions to finalise the data collection process.

The analysis will seek to determine the effectiveness of the deployment of firearms in operational circumstances, comparison between frequency and types of firearms skills training and determining

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the most likely police shooting situations for police in Australia. It is expected the data, when fully assessed, will help to inform discussions on the frequency of live firearms training.


The QPS is analysing data collected from other jurisdictions and will produce a report on the deployment of firearms in operational circumstances. The report will inform discussions on the frequency of live firearms training at the QPS. The Ethical Standards Command commenced a separate more detailed research project which will complement this body of work.


Operational Training Services reviewed the frequency of police firearms skills training and evaluated

officers’ performance in shooting situations by analysing fatal and non-fatal shootings in Queensland

between 1 June 2006 and 1 January 2018. The review identified that police engage the intended

target with an 82% success rate, indicating police firearms training is successful in preparing police

for the likely expectation of a shooting incident. In addition to live fire on a range, the Queensland

Police Service performs annual dynamic scenario training which involves role playing in realistic

situations using service weapons that fire paint projectiles. This situational shooting scenario

training is high fidelity training that is more impactful than shooting live ammunition at static paper

targets.

The current frequency and manner in which firearms skills are taught and maintained is highly successful and the evidence does not support an increase in live fire practice for frontline non-specialist officers.

Recommendation 6 The Queensland Police Service continue to explore ways in which use of force training in low light conditions can be effectively delivered, including through the use of purpose built and dedicated facilities to assist in the delivery and frequency of this training.




The development of the new Counter Terrorism and Community Safety Centre (CTCSC) at Wacol,

due for completion in late 2020, will provide low light training environments for police operational

skills and tactics (OST) training. This centre will significantly enhance the quality and capacity to

deliver relevant and applicable multi-disciplined OST training to all police. The centre is programmed

to provide OST training to all operational police within the South East Corner of Queensland,

however, a review by an external benefits analyst is underway to establish whether a state-wide

rollout of training within the centre is viable.

The QPS rolled out 9500 weapon mounted light systems to operational police and was incorporated into the compulsory annual OST training for all police officers. This weapon mounted torch will enhance officer safety and increase operational effectiveness in low light policing situations.

Recommendation 7 Operational skills and tactics training continue to incorporate 'lessons learned' from previous shootings into scenario based training, including anticipating the presence of weapons on arrival at the scene, tactical withdrawal, and managing bystanders during an incident.


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The Queensland Police Service is developing additional theoretical training opportunities to be

conducted during the annual operational skills and tactics training to complement and support the

interactive scenario-based training. This may include officers watching videos and reading other

relevant material as they become available.

The Dynamic Interactive Scenario Training (DIST) is reviewed annually, and incorporates lessons learned and current operational and threat environment factors.


Annual skills training for 2017-18 and 2018-19 includes dynamic interactive scenarios that

incorporate lessons learnt including the presence of weapons, tactical withdrawal and positioning,

and managing bystanders during an incident. Annual dynamic interactive scenario training is

intentionally inclusive of lessons learnt and recent, relevant operational experiences. The

development of curriculum in this space is heavily based on the operational environment and

relevant experiences.

Furthermore, the additional theoretical training opportunities, which complement and support the interactive scenario-based training, were developed and have now been incorporated into operational skills and tactics training.

Recommendation 8 The Queensland Police Service conduct a review of the standing orders governing the conduct of Ethical Standards Command (ESC) investigations of critical incidents involving a fatality. The review should include the following matters for the consideration of investigators:

a. Where it is desirable to defer an interview with the ESC investigator (including for the welfare of involved officers), or impractical for that interview to occur close to the time of the incident, an initial account of events should be taken in a short interview recorded by a suitably independent, but readily available, investigator. The officer conducting this initial interview should be someone whose involvement is approved by the person directing the ESC investigation, but need not be that officer or an ESC officer.

b. A restatement of the advantages of walk-through interviews as the primary means of obtaining the account of involved police officers, while leaving the means of the primary interview to the discretion of the investigator.

c. Provision for officers to be given the opportunity to view relevant video or other recordings, including body worn camera footage, of an incident at a time considered appropriate by the investigator but not before the primary interview; and an opportunity for officers to provide addendum statements or take part in addendum interviews where either officers or investigators consider that desirable.

d. All forensic testing of involved officers should be conducted within two hours of the incident occurring.

e. A separate senior ESC officer should be given oversight of actions concerning involved officers, including officer separation; initial interviews; forensic testing; issuing instructions; sending officers home if appropriate; transporting and accommodating officers; providing a change of clothes etc.

Response and action: the recommendation is agreed in part and implementation is complete.



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The Queensland Police Service (QPS) Ethical Standards Command (ESC) conducted a full review of

the instructions governing the conduct of investigations into police related incidents involving a

fatality. The instruction has been amended to reflect most of the recommendations made by the

coroner. The instructions were implemented on 29 November 2017.

Recommendation 8d is supported in part. The QPS conducts forensic testing of all officers involved in critical incidents which may include the collection of DNA and clothing, seizure of accoutrements and collection of blood/bodily fluid contaminates. Pursuant to Part 5A of the Police Service Administration Act 1990 (PSAA), a breath test is to be conducted within 2 hours of the critical incident occurring and a urine drug screen is to be completed within 24 hours.

While the QPS adheres to the PSAA and completes all breath tests within 2 hours and drug screen tests within the 24-hour period, it is impractical for the QPS to complete drug screens (in addition to other testing requirements) within 2 hours of a critical incident, as recommended by the coroner. The QPS endeavours to complete all required testing following a critical incident as soon as practical. Within the last 20 years, the QPS attended over 200 critical incidents and completed the required testing within 12 hours of the incident occurring.

Recommendation 9 The Queensland Police Service consider adopting service-wide an approach analogous to the system employed by Special Emergency Response Team for post incident support of officers, subject to appropriate adaptations having regard to local circumstances and officers being trained as to the limits of their role.




The Queensland Police Service reviewed and amended its current instruction to reflect the

recommendation made by the coroner. The revised instruction now aligns with the approach

employed by the Special Emergency Response Team (SERT) for post-incident support of officers.

The revised instruction states that ‘a welfare officer is appointed from the District or Command, to

attend to the welfare needs of the subject members, including identifying a support person not

involved in the incident to remain with the subject member; transporting the subject member from

the scene to a police establishment; in circumstances requiring forensic examination of the subject

member and/or clothing, arranging a change of clothing to be provided once forensically dealt with.

The welfare officer is to ensure support persons are aware of the direction for the subject members

to be separated and not to discuss the matter’.

The instructions were implemented on 29 November 2017.

Recommendation 10 Officers involved in a critical incident involving a fatality be mandated to attend at least one session with a psychologist or psychiatrist independent of the Queensland Police Service (QPS) and that this issue be the subject of a separate review by the QPS. The review should consider:

• the most effective ways of supporting police officers after a critical incident involving a fatality in the medium to long term

• the training of officers in supervisory positions to ensure that they can appropriately monitor officers under their supervision who have been involved in critical incidents involving a fatality; including an awareness of warning signs that an officer is experiencing

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difficulties; and of steps that can be taken to ensure that such officers receive timely support.

• how appropriate support mechanisms can be established and how the adequacy of existing mechanisms is monitored.

Response and action: implementation of the recommendation is in progress.



The Queensland Police Service (QPS) proposes to engage the Melbourne-based company, Phoenix,

formerly known as the Australian Centre for Post-Traumatic Mental Health, to complete a review of

QPS’s policy, systems and processors for supporting and monitoring employees involved in critical

incidents and the appropriateness of referrals to psychiatrists and/or psychologists for mandatory

assessment following a critical incident. In the interim, the QPS will continue to review the coroner’s

recommendation with a view to continuous improvement of these services.

The QPS is also considering some of the recommendations from the Queensland Audit Office Report

into Mental Health Services. Furthermore, in February 2018, the QPS launched the Our people

matter strategy which focuses on the health, safety and wellbeing of QPS members and their

families. The strategy will connect the needs of frontline management and supervisors with

solutions and support mechanisms to create working environments that will protect the long-term

health and wellbeing of employees. The QPS intends to provide refresher training courses to

supervisors to build their knowledge and capability, and to provide options for supporting members

during and post critical incidents. All mental health training, including program design, content and

frequency will be reviewed in 2018 to ensure the issues outlined in the coroner’s recommendations

are consistently addressed and reinforced in all programs.

Additionally, the QPS has a range of personnel including 600 peer support officers and thousands of supervisory staff including 24 psychologists and social workers whose roles are to monitor and refer their staff and colleagues who may exhibit distress and or any behaviours that require debriefing and or mental health support. The QPS has internal and external counselling and support options and refers more than 600 officers requiring paid treatment to psychologists or psychiatrists each year. The QPS also engages more than 32 chaplains in voluntary, part-time and full time roles to support all geographical areas of the state.


The Queensland Police Service is conducting a number of reviews to help inform how the service can

support officers after a critical event. The conclusion of these reviews will assist the QPS in how to

implement the coroner’s recommendation.

The QPS is participating in a review led by the Office of Industrial Relations (OIR) with WorkCover

Queensland, aimed at improving support to members with PTSD and improve workers’

compensation claims processors (which includes assessing the process barriers and assessing the

need for more timely support). The Queensland Police Union is participating in the review. Phoenix

Australia was engaged by OIR to examine existing processes at WorkCover Qld and within the QPS.

As mentioned in our earlier response in July 2018, Phoenix Australia will also review this coronial

recommendation and recommendations arising from the Queensland Audit Office report which

relate to mental health literacy and mental health screening within the QPS.

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The QPS commenced implementation across all police districts of the Our People Matter Strategy, which focuses on improving workplace safety and relations and the health and fitness of QPS employees and their families. The strategy was developed in partnership with employees, their families and unions.


Phoenix Australia completed their review of post-traumatic stress disorder workers’ compensation

claims for frontline workers in Queensland, which is now with OIR. OIR indicated they will discuss the

review findings with their minister and key stakeholders including Workcover Queensland, frontline

responder agencies and the Queensland Police Union of Employees.

Phoenix Australia also completed a review of the mental health screening instruments used by the

QPS for the identification of employee psychological distress. These screening tools were validated

as appropriate for use within the QPS workforce which includes support mechanisms for

overviewing attendance at critical incidents.

The QPS will request Phoenix Australia to specifically review the QPS systems for the management

and support of employees involved in fatal critical incidents and to advise on improvements. This

review will build on the related knowledge and examinations Phoenix Australia obtained in their

reviews on aspects of mental health support services available to QPS employees which was

finalised in November 2018.

The QPS will also benchmark the management and support programs offered by other Australian policing organisations as part of the Phoenix Review and QPS continuous improvement.


As the review being conducted by Phoenix Australia forms part of a larger body of work being led by

another department, the Queensland Police Service has requested Phoenix Australia provide advice

specifically on the merits of requiring police officers to attend a session with a psychiatrist or

psychologist following a critical incident involving a fatality.

The Queensland Police Service established a mental health literacy framework to build capability and knowledge in our workforce. The training of frontline, middle management and senior leadership will incorporate theory and practical information on how to identify, monitor and support employees experiencing difficulties.

The Queensland Police Service updated the psychological first aid training for leaders which includes embedding scenario-based training within the incident command course. This will be rolled out in future incident command training courses and leadership development programs (commencing 2020).

On 5 August 2020 the Minister for Police and Minister for Corrective Services responded:

The Queensland Police Service has redrafted the psychological first aid policy for review by Phoenix Australia.

The Queensland Police Service will be updating the online learning package that supports the application of psychological first aid policy in the work environment, once the policy has been formally reviewed and endorsed by Phoenix Australia. Psychological first aid training for leaders will be developed for inclusion within the service’s leadership capability program.

http://ourpeoplematter.com.au/

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On 2 October 2020 the Minister for Police and Minister for Corrective Services responded:

In August 2020, the Queensland Police Service obtained the Phoenix Australia’s final report

Queensland Police Service Review of the current approach to managing critical incidents and

potentially traumatic events. Phoenix Australia provided a series of recommendations to support

the broader integration and approach to mental health and wellbeing across the organisation which

include:

• transitioning the service to a comprehensive and consistent psychological first aid response

to critical incidents and potentially traumatic events

• development and implementation of guidelines for monitoring cumulative exposure to

critical incidents and potentially traumatic events

• embedding psychological first aid in existing police training at all levels

• implementing compulsory training and support for all supervisors, managers and peer

support officers directly linking to respective roles and responsibilities

• developing a process for employees to anonymously monitor their own psychological

wellbeing in order to facilitate early identification, encourage self-care and promote help-

seeking

• considering the provisions of mandatory post-incident screening in the event of a high-level

exposure to a critical incident, providing an additional layer of support alongside current

psychological first aid and self-help options in the event of these high-risk situations.

The Phoenix review supported the concept of mandating sessions following a critical incident

involving a fatality to demonstrate the Queensland Police Service’s duty of care, provide a

method of capturing any residual mental health issues as a result of cumulative exposure, and to

reduce the stigma associated with early intervention and attending sessions with a mental

health professional. The review also stated however, that there is no definitive research

evidence to support the effectiveness of mandatory screening post a critical incident, noting the

approach needs to be agency-specific and contingent on the integration of policies and practices

within the organisation’s overall approach to mental health. Phoenix Australia recognise the

benefits of mandatory screening after a critical incident relate more so to the capture of

cumulative trauma, rather than providing support following a critical incident.

The report acknowledged the development of the Queensland Police Service policy on

psychological first aid and the provision of support following a critical incident or potentially

traumatic events will provide an opportunity for employees to receive care tailored to their

needs, with those requiring formal (level 3) treatment referred to an external mental health

professional. In this context, the review recommended the Queensland Police Service consider

de-coupling mandatory screening from critical incidents and provide regular (annual) mandatory

screening by a qualified mental health professional for all employees. This will broaden the

potential for mandatory screening to capture distress associated with cumulative critical

incidents and potentially traumatic events exposures and other organisational and personal

stressors.

A dedicated project was established to progress the development of a Queensland Police Service

wellbeing strategy which will adopt an integrated approach aimed at protecting the mental

health of staff, promoting wellbeing and addressing mental health conditions regardless of

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cause. In addition to implementing the recommendations from the independent Phoenix review,

the project team identified five key priority areas of leadership, culture, education, health and

wellbeing services and employee lifecycle initiatives with work currently progressing to:

• review injury management

• establish a Queensland Police Service funded and anonymous self-refer external counselling

program to reduce barriers and encourage employees to seek early assistance. This network

could be utilised to implement the Review recommendation to provide annual screening to

all employees

• deliver a mental health training framework

• deliver a comprehensive external wellbeing and support website

• review the organisation’s approach to supporting members who experience a critical

incident or potentially traumatic event through the provision of psychological first aid

• review the peer support officer program.

The Queensland Police Service will undertake several bodies of work, including:

• commencing consultation with relevant stakeholders to develop a broader integration of

psychological first aid and wellbeing services

• revising the psychological first aid policy and guidelines with respect to the provision of a

comprehensive and consistent psychological first aid response to critical incidents and

potentially traumatic events

• commencing a review of relevant internal systems to identify a suitable system-based

solution/s to support mental health case management and tracking of cumulative exposure

• ongoing development to refresh psychological first aid training across all levels of the

organisation in accordance with the revised policy and guidelines. The Queensland Police

Service will provide psychological first aid training as a foundational course for all members,

within the leadership training program and embedded throughout skills programs including

incident command.

In light of the Phoenix report recommendations, the Queensland Police Service will examine options to provide opportunities for an annual check in with an external psychologist to monitor cumulative exposure, reduce stigma and facilitate proactive help seeking behaviours.

Recommendation 11 The Queensland Government develop appropriate referral pathways, through an agency such as Victim Assist Queensland, to enable the families of those shot by police and witnesses to such events to be provided with counselling and support.




The Queensland Police Service has existing policies and procedures in place to support families and

witnesses in the event of a fatal police shooting incident. For example, where the next of kin of the

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deceased agrees to the release of their information to the Queensland Homicide Victims Support

Group (QHVSG), the notification is emailed by police to the QHVSG within 24 hours of the

commencement of the investigation. The QHVSG offers 24-hour emotional support, personal

advocacy and information to all people affected by homicides in Queensland. Significant changes to

the Victims of Crime Assistance Act 2009 in 2017 strengthened victims’ rights through the

replacement of the ‘Fundamental Principles of Justice’ with the ‘Charter of Victim Rights’. The

charter requires police to proactively provide victims of an act of violence in Queensland with

information about the victims’ register, investigations and prosecutions without the victim having to

ask for the information.

The QPS has connected vulnerable and disadvantaged people who may be experiencing stress,

distress and a range of social issues, with support services since 2005 under different support

program names. Police Referrals is the name of the current program and is an embedded strategy of

QPS frontline operational policing. Police Referrals continues to be developed to ensure frontline

officers are able to provide individuals, their families and carers the option of a referral to local

service providers.

Police Referrals has over 450 service providers for any one of 23 different referral categories. One of

the referral categories relates to provision of counselling and support to family members and

witnesses following a fatal police shooting. Once a referral is made, the client is contacted within a

few business days by the relevant support provider.

A network of officers provide local ‘on the ground’ support and education to district police about the service’s referral approach, work with local service providers to ensure appropriate services are receiving police referrals and assist in resolving issues regarding local service provision. The network liaises with other officers responsible for delivering community-based policing initiatives to support vulnerable persons e.g. Domestic and Family Violence Coordinator, Mental Health Intervention Coordinator.

The QPS is improving the Police Referrals program by identifying ongoing system improvements

including possible new referral categories.

The Charter of Victims’ Rights requires all agencies who engage with victims, to ensure victims are

given information as soon as possible about services which may aid them in their recovery. The QPS

has Police Referrals to ensure timely services are provided to all victims. Victim Assist Queensland

(VAQ), which operates within the Department of Justice and Attorney-General, is a service provider

under the Police Referrals program. VAQ provides a wide range of services to victims of crime

throughout the state, including information and referral to support services around Queensland. A

dedicated police officer is appointed to act as a conduit between the QPS and VAQ to expedite the

exchange of information directly to VAQ in accordance with legislative requirements, including

providing progress updates on investigations.

The QPS is developing referral cards to give to people who initially decline an offer for a referral but may later change their mind.


As a result of the recent amendments to the Victim of Crime Assistance Act 2009 (the Act), the QPS

made a number of enhancements to the police referrals systems which were released in July 2018.

These enhancements, which includes a sudden death support referral, help to ensure victims

continue to be provided with the necessary support services. In future, when an officer responds

‘YES’ to the question ‘Has the referred person been involved in act of violence against the person,

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and requires information on Victim Assist Queensland services’, the system will automatically add a

referral to VAQ in addition to the referral to other specialist service providers.

The definition of a victim under the Act includes:

• primary victim

• parent/secondary victim/s

• family of the deceased

• any witnesses (who hear and/or see an act of violence).

All these members are eligible to be referred to VAQ.

The QPS is continuing to progress development of referral cards to be provided to victims of crime who initially decline a police referral to a support service.


Police referrals has over 480 service providers for 23 referral categories including a mental health

referral category; support for the person with mental health issues; support for family/carers; and

veteran support (with all referrals going to the Returned Services League Australia). Victims Assist

Queensland is one of the many referral categories victims of crime may be referred to by police.

The QPS referral card has been designed and approved and will be progressing to print.

Recommendation 12 The Queensland Government conduct a comprehensive review of the mental health intervention portfolio/project (MHIP) to ensure the revitalisation of the MHIP as recommended by the violent confrontations review (VCR) recommendation 2, and its sustainability. The review of the MHIP should consider: • the establishment of full time dedicated Mental Health Intervention Coordinator (MHIC) in

each police district • the establishment of full-time dedicated MHIC roles in each police region • the extension of the hours of operation for the mental health clinicians embedded within

the Brisbane Police Communications Centre to 24 hours a day, 7 days a week • a model for dedicated training to take place for police officers and mental health clinicians

involved in the MHIP • the governance framework in place with respect the MHIP with a view to ensuring a level of

consistency across the State, and the exchange of information between QPS districts and hospital and health services

• a review of each police district to ascertain whether a co-responder model is in place and possible expansion of the model to all districts

• how to embed mental health training within annual Operational Skills and Tactics (OST) training. The training should be dynamic, scenario-based, and include communication and de-escalation skills and be delivered with the assistance of mental health professionals and those who have ‘lived experience’ of mental health or cognitive disabilities

• the inclusion of appropriate flags in Q-Prime to alert Queensland Police Service officers to relevant mental health history.

Response and action: implementation of the recommendation is in progress.

Responsible agency: Queensland Police Service (lead) supported by Queensland Health.


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The recommendation is under review. An update will be provided in 2018.

On 1 November 2018 the Minister for Police and Minster for Corrective Services and the Minister for Health and Minister for Ambulance Services responded:

The QPS is working towards the revitalisation of the Mental Health Intervention Portfolio (MHIP) as

considered under recommendation 2 of the QPS violent confrontations review (VCR). This body of

work is ongoing and to date has included:

• the development of the QPS Strategy for the Prevention and Resolution of Policing

Involvement in Mental Health 2017-2020

• embedding the MHIP state coordinator role into the Domestic, Family Violence and

Vulnerable Persons Unit

• re-vitalising annual mental health intervention coordinator (MHIC) workshops including

attendance of Queensland Health (QH) MHICs and presentations by persons with lived

experience

• re-establishing annual mental health funding for the regions

• a mental health intervention coordination and training compliance inspection by Ethical

Standards Command.

The QPS, QH and Queensland Ambulance Service (QAS) commenced a joint review of the MHIP (the

review) in March 2018. A working group comprised of members from all three agencies has formed

and provides reports on the progress of the review to the QH, Mental Health and QPS Steering

Committee.

The objectives of the review are to:

• establish whether current operations meet the intention of the program

• establish whether the program’s original aim meets contemporary needs in relation to

persons with impaired mental capacity and interactions with police particularly at times of

crisis

• propose and implement an appropriate model for the MHIP which meets contemporary

needs and ensures sustainability of the program into the future.

The following considerations, as outlined by the coroner above, are in-scope of the review:

• establishment of a full time dedicated MHIC in each police district

• establishment of a full-time dedicated MHIC roles in each police region

• extension of the hours of operation for the mental health clinicians embedded within the

Brisbane Police Communications Centre to 24 hours a day, 7 days a week

• a model for dedicated training to take place for police officers and mental health clinicians

involved in the MHIP

• the governance framework in place with respect the MHIP with a view to ensuring a level of

consistency across the state, and the exchange of information between QPS districts and

hospital and health services

• a review of each police district to ascertain whether a co-responder model is in place and

possible expansion of the model to all districts.

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The review is planned for completion by the end of 2018.

Mental health flags already exist in QPS’s information management system, QPRIME, and officers

are encouraged to check the system to ascertain if there is a history of mental health when

attending jobs.

QH is working closely with the QPS as part of their enhancements to the QPS MHIP. Additionally, a

number of relevant programs and initiatives have been established to support the relationship

between the mental health sector and the QPS in order to improve responses and outcomes for

persons with a mental illness who interact with the police. These initiatives include:

• A mental health/police steering committee was established to oversight the range of

collaborative projects and interfaces across QH and the QPS. This committee meets

quarterly, and its membership includes the chief psychiatrist, the statewide director,

Forensic Mental Health Service and four assistant commissioners from the QPS.

• QH provided recurrent funding to the Police Communications Centre Mental Health Liaison

program in 2016 to ensure this service is available to support police seven days per week

(each weeknight and on weekends). Additional recurrent funding through the QH

Connecting care to recovery mental health plan is to be provided in 2019-20 to further

enhance this service.

• An evaluation of the implementation of the Mental Health Act 2016 is currently being

undertaken by QH and includes consideration of the inter-agency collaboration across QPS,

QH and QAS in relation to individuals who may be subject to the Mental Health Act.

• Communication protocols between QH mental health services and the QPS to advise of

changes in care status (including discharge from care) for consumers brought to emergency

departments by the QPS are under development. The disclosure of information will occur

under a memorandum of understanding (MOU) between QH and the QPS for confidential

information disclosure which was finalised on 29 March 2018. The MOU is to be prescribed

in the latter half of 2018.

• QH also provided additional recurrent funding to the joint mental health and police

Queensland Fixated Threat Assessment Centre from 2017-18 to expand service provision in

this initiative.

Outcomes from the review will be presented to the QH, Mental Health and QPS Steering Committee,

and each agency’s executive leadership team for consideration.

On 2 May 2019 the Minister for Police and Minster for Corrective Services and the Minister for

Health and Minister for Ambulance Services responded:

The MHIP review commenced in 2018 to examine the viability of the recommendations as outlined

in this recommendation. In 2018, the MHIP review has achieved the following progress:

• QPS district officer consultations and interviews have been completed with responses

transcribed and currently under further analysis

• QH and QAS have provided input into the review of the MHIP. Their responses are being

analysed for inclusion in the final report

• analysis of the MHIC role is currently being reviewed with findings to be included in the final

report

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A model for dedicated training to take place for police officers and mental health clinicians will be

considered as part of the MHIP review.

The review of the co-responder model will commence following the appointment of the mental

health senior policy officer in QPS. The position is expected to be filled in the first half of 2019.

Scoping of the MHIC roles at both QPS district and regional levels is now complete with findings to

inform the broader MHIP review.

This expansion has been driven at a local level by QPS districts and local hospital and health services.

The models vary depending on district needs and resources. Future evaluations of the models will be

used to inform consideration of further expansion.

• There are currently six co-responder models throughout Queensland at varied stages of

formalisation. A further two co-responder models are set to commence in the first quarter

of 2019 in South Brisbane and Logan districts.

• In October 2018, the revised mental health intervention package was updated to reflect new

legislative amendments and went live in the QPS learning management system. This training

was specifically designed to refine and upskill first response officer knowledge and protocols

when attending situations where a person is experiencing a major behavioural disturbance,

disabilities, acquired and traumatic brain injury, comorbidity and exhibiting episodic

behaviour.

• The face-to-face training is currently being rolled out to QPS education and training officers,

MHICs and negotiators who will be co-facilitating this training, to first year constables. All

first year constables will undertake this training within the first 12 months of being sworn in

as a police officer. The first year constable mental health training provides officers with a

review of the mental health legislation and currency in dealing with persons in crisis. The

training focuses strongly on providing a deeper and contextual understanding of mental

impairment and the ongoing implications for the individual and family members. Police

officers are provided strategies to enhance their response to a mental health crisis. The

training incorporates topics on language, stigma, de-escalation communication, suicide,

disability, mental impairment, co-morbidity and understanding the importance of co-agency

collaboration practices.

• QPS learning products and resources are constantly reviewed to reflect changes in practice

and legislation to ensure a holistic response to persons in crisis.

In 2019 work will be undertaken to complete a funding and resourcing analysis of the MHIP, an

evaluation of the co-responder model and establish a new MHIP framework and implementation

plan.

On 26 November 2019 the Minister for Police and Minister for Corrective Services, and the

Minister for Health and Minister for Ambulance Services responded:

The Queensland Police Service continued to progress the coroner’s recommendation. In the January

to June 2019 reporting period, the QPS achieved the following progress:

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• progressed the review of MHIP, with initial findings from this review planned for delivery in late 2019

• appointed a Queensland Police Service mental health senior policy officer

• commenced the review of the co-responder model, including: conducting desktop research

(international and national literature review) to identify benefits and limitations of such

models; and engaging with each police district to ascertain if co-responder is operating in

their district.

The Queensland Police Service will review and consider the findings of the MHIP.

On 3 June 2020 the Minister for Police and Minister for Corrective Services, and the Deputy

Premier and Minister for Health and Minister for Ambulance Services responded:

The Queensland Police Service continued to progress the coroner’s recommendation and:

• completed the review of the co-responder model, with findings incorporated into the draft

MHIP review outcomes report

• finalised the draft MHIP review outcomes report for consideration by the Tri-Agency Mental

Health Steering Committee in early 2020

• released the Queensland Police Service electronic Competency Acquisition Program training

product responding to mental illness’ which provides training to frontline police and includes

information on cognitive impairment.

The Tri-Agency Mental Health Steering Committee comprised of representatives from Queensland

Police Service, Queensland Health and Queensland Ambulance will consider the draft Mental Health

Intervention Review Outcomes Report in 2020.

Recommendation 13 The Queensland Police Service amend Chapter 6 of the Operational Procedures Manual (OPM) so that that there is no need for a police officer to subjectively assess whether the situation is a ‘mental health incident’ as defined currently within the OPM. The OPM should be drafted in such a way that frontline police are encouraged to call for mental health assistance in respect of incidents.



On 2 May 2019 the Minister for Police and Minster for Corrective Services responded:

The Queensland Police Service (QPS) Operational procedures manual (OPM) and the First response

handbook were amended to reflect the coroner’s recommendation. The amendments were

published on 24 January 2018.

In making an informed decision on the most effective and appropriate policing response, officers

attending an incident need to consider whether the occurrence falls within the definition of a mental

health incident. If deemed a mental health incident, officers should as soon as reasonably

practicable, seek advice or information regarding the subject person from the relevant Queensland

Health mental health service to ensure the health and safety of the person in crisis or any other

person. Based on the availability of mental health clinicians, the following types of responses

available to assist police including assistance from: the local mental health unit, either in-patient or

community centre; the mental health clinician, placed in the Brisbane Police Communications

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Centre; or a co-responder (i.e. in some police districts a team comprising a police officer and mental

health clinician are available to respond to mental health incidents), if available in the identified

location.

In addition, located in the QPS districts is a network of police officers (mental health intervention

coordinators) who:

• provide direction, guidance and advice to Service members and the community, on issues associated with mental health issues

• assist district education and training offices in developing and conducting education and training on legislation, policy, orders and procedures, including associated issues in dealing with mental health issues

• overview the development and standardisation of district instructions relating to mental health incidents

• provide assistance to officers in the assessment and response to mental health incidents according to local protocols and where necessary, assisting with requests for information from Queensland Health and the Queensland Ambulance Service.

Recommendation 14 The Queensland Police Service retain mental health training as a core component of the recruit and first year constable training programmes.




Queensland Police recruits undertake all components of the vulnerable persons training, which

consists of mental health training and domestic and family violence training.

The mental health training component enables participants to identify and understand

characteristics of impaired mental capacity; to understand and appreciate the policing with influence

model for verbal de-escalation in a policing context; and to apply effective communication skills for

responding to and managing situations where a person presents with an impaired mental capacity in

accordance with legislation.

Police recruits undergo further scenario-based training which is assessed during skills training

phases.

The first year constable program continues to provide the mental health intervention training package which is delivered to all first year constables by education and training officers across the state.

Recommendation 15 The Queensland Government continue to allocate funds to the body worn camera roll out to enable all front line officers to be equipped with this technology.




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In 2015, the Queensland Government allocated $6 million to provide body worn cameras for the

operational police. The Queensland Police Service (QPS) utilised this funding for stage one of the

body worn camera project which delivered 2700 body worn cameras to frontline police officers. In

2016, the QPS provided an additional $1 million for the stage two rollout which delivered a further

2400 body worn cameras to frontline police. This brought the total number of devices deployed to

5100.

An additional 2,000 body worn cameras are required in order for all operational police officers to be

equipped with this device. The QPS will work with the Queensland Government to continue to

identify efficiencies and provide funding for additional body worn cameras for all frontline police

officers.

Current QPS policy also allows the use of ‘bring your own’ (BYO) body worn cameras by frontline police officers, subject to approval and conformance to performance specifications.

The QPS remains committed to further enhancing our mobile capability and this initiative will remain at the forefront of QPS’s funding priorities into the foreseeable future. The allocation of body worn camera devices is currently being reviewed to ensure the most effective and equitable distribution to frontline officers across the state.


The QPS is continuing to identify efficiencies to fund the rollout of body worn cameras to all frontline officers.


The Queensland Police Service continues to review distribution of body worn cameras to frontline officers.


Additional funding was committed to continue the body worn camera program for a further three years. It is expected this will increase the number of body worn camera devices to 7,700 devices by 2021-22.

On 5 August 2020 the Minister for Police and Minister for Corrective Services responded:

The supply and deployment of the 7,700 body worn cameras was rolled out ahead of schedule.

Recommendation 16 The Queensland Government consider whether a scheme for the regulation of replica firearms with linkages to relevant Queensland Police Service intelligence holdings should be established in Queensland, having regard to interstate legislation and the work of the national Firearms and Weapons Policy Working Group.




The Queensland Police Service (QPS) implemented the recommendation when it considered a

scheme for the regulation of firearms with linkages to relevant QPS intelligence holdings, as

suggested by the coroner. The QPS decided not to support such a scheme for the following reasons:

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• a person may be in possession of more than one replica, imitation or genuine firearm, some

of which may not be registered in Queensland

• some replica or imitation firearms are capable of firing lethal and non-lethal ammunition

which compromises an officer’s safety

A person in possession of any weapon, including a replica or imitation firearm, is currently recorded

as a weapons holder in Queensland. The QPS’s information management system, QPRIME, does not

specify if the weapon is a genuine, imitation or replica firearm for the reasons listed above, and to

ensure officer safety.

The current legislation has been successful in controlling and regulating the licensing and use of actual weapons and allows for imprisonment and fines for the misuse of replica weapons.

Recommendation 17 The Queensland Police Service continue to provide Special Emergency Response Team officers with training in negotiation and de-escalation skills to ensure that they are equipped to deal with parties in siege situations and other high risk environments.




In October 2016, the Negotiator Coordination Unit delivered training on communication and de-

escalation skills at high risk incidents to officers from the Special Emergency Response Team (SERT).

In addition, the Queensland Police Service (QPS) also delivered vulnerable persons training to all

frontline police officers which included a component on ‘understanding a person in crisis and the

effects of mental health issues in the communication process’.

This training will be reviewed annually to ensure it remains contemporary, and will also form part of

SERT’s ongoing training requirements.

SERT continues to be involved in national team leader courses, tactical commander courses and operator skill enhancement courses across the nation. This allows the QPS to benchmark its systems, processes and skills against police tactical group units across Australia and New Zealand, and enhance its tactical response.

Recommendation 18 The Queensland Police Service continue to examine the way in which it deals with threats to the public interest arising from nuisance calls, with a view to continuous improvement in the communication training made available to all call takers with respect to dealing with callers who may have a mental illness and/or cognitive impairment. Such examination should address both training and technology solutions.

Response and action: the recommendation is agreed in part and implementation complete.



The Queensland Police Service (QPS) is committed to ensuring its service response remains

contemporary and reflective of emerging trends related to threats to the public interest arising from

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nuisance calls, and offenders who have a history of mental health, whilst maintaining the safety of

all Queenslanders. Activities include:

• Training for new communications operators was updated in 2016 with the implementation

of the current communications operator course. This training provides operators with the

skills necessary to manage nuisance calls and threats, and offenders who have been

identified with a history of mental health. This training also encompasses a component on

vulnerable persons focused on mental health. Building on this work, a continuous

improvement process has been established to review and update training for

communications operators and supervisors. This process allows for incremental

improvements to be made to the training program and content as legislation and

operational methods change, and updated advice is received from relevant partner agencies.

• Policelink call takers (both sworn and non-sworn) participated in the vulnerable persons

training in 2017 which included scenarios in the mental health face-to-face session to refresh

and practice de-escalation techniques. It is planned to enhance future iterations of the

Policelink-specific training curriculum with soft skills call control to ensure call takers

maintain necessary skills required to effectively communicate with persons in crisis.

• Policelink implemented a case management approach to occurrences, assisting mental

health intervention coordinators to better assess risks to make an informed decision on a

course of action e.g. referral to mental health services where appropriate, or in some cases

prosecution.

The QPS reviews the training requirements for communication room operators and supervisors

annually and incorporates lessons learned as required. Additionally, the annual training curriculum

for police communication centre staff is currently under review by the communications group.

Regarding technology, the QPS through its business improvement unit regularly considers opportunities to enhance the service’s frontline policing capability, including frontline information and communication technology systems, and through engagement with portfolio partners.

At this point in time the current QPS systems utilised by communication centre, namely the Queensland computer aided despatch system (QCAD), are considered operationally fit to meet the requirements of the recommendation. QCAD interfaces well with internal/external QPS systems to deliver an effective tool for the management of the communications network. The QPS has additional integration capability with QCAD through inter-agency CAD electronic messaging system (ICEMS). ICEMS allows for instant messaging between Queensland emergency service providers including the Queensland Ambulance Service, and Queensland Fire and Emergency Services. This allows for instantaneous transfer of calls for service between emergency service agencies.


The communications group training curriculum now includes mental illness/cognitive impairment in its training delivery. The training incorporates examination of threats to the public arising from nuisance telephone calls.

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Recommendation 19 The Queensland Police Service (QPS) incorporate options for dealing with nuisance callers in relevant standing instructions and mandatory training for call takers including:

• early diversion to PoliceLink or another support agency, including the caller’s primary

clinician

• interrogation of Q-Prime to ascertain relevant mental health history

• giving local station shift supervisors discretion in dealing with the situation (including

by calling the nuisance caller)

• engagement of mental health clinicians embedded in QPS communications centres

• engagement of QPS trained negotiators.

Response and action: the recommendation is agreed in part and implementation complete.



The Queensland Police Service (QPS) has various protocols in place to deal with situations involving

nuisance calls and offenders who have a history of mental health.

The QPS’s current telephone system permits triple zero calls from the police communications

centres (PCC) to be transferred to Policelink and into referral services, which could include the

caller’s primary clinician.

Station supervisors maintain oversight of the jobs/calls for service for their designated station, and

have the option to intervene in matters involving nuisance calls in an attempt to resolve the

situation in a timely manner. To facilitate this, station supervisors may contact the nuisance caller

direct and/or send a crew to their residence, in addition to checking QPRIME to ascertain relevant

mental health history and if there was a history of repeat offences.

The QPS engaged four mental health intervention coordinators (MHIC) from Queensland Health.

These MHICs are currently embedded in the Brisbane Police Communications Centre and provide

support to officers across the state in dealing with offenders and/or witnesses who have a history of

mental health. In addition, there are also mental health liaison officers in regions and districts across

the state who provide a point of reference and referral of mental health related matters.

The PCC will only engage trained negotiators for serious incidents. Negotiators are a specialist

resource that are utilised in high risk environments for serious incidents, and are generally not

engaged for incidents only involving nuisance calls. However, in 2017, the QPS delivered the

vulnerable persons training package to over 11500 sworn members, up to and including the rank of

inspector, and targeted unsworn members from Policelink and the PCC’s. The training encompassed

components on negotiation and dealing with offenders and/or members of the public who may have

a history of mental health.

Modifications have been made to the communications operator training to include content from the

vulnerable persons training package, and all instructions in relation to this training and PCC

processes have been updated to reflect current practices. A modified vulnerable persons training

package has been developed specifically for communications operators. It is anticipated that

delivery of this training will commence in the second half of 2018.

Additionally, the annual training curriculum for PCC staff is under review by the communications

group with the aim of expanding the content to include a component on negotiation.

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The annual training curriculum for PCC staff was updated to include mental illness/cognitive

impairment. The training incorporates examination of threats to the public arising from nuisance

telephone calls.

The following options answer the coroner’s recommendation in relation to nuisance callers:

• Callers can be transferred to Policelink and support agencies (including the caller’s primary

clinician) by QPS call takers.

• Call takers can check QPRIME to ascertain the caller’s relevant mental health history.

• Station supervisors can maintain oversight of calls and have the option to intervene.

• Mental health intervention coordinators are embedded in the Brisbane Police

Communications Centre to provide support across the state.

Negotiators are generally not engaged for nuisance calls, however sworn and unsworn members

receive vulnerable persons training.

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